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Delayed gastric emptying (DGE) is common after an Ivor Lewis gastro-esophagectomy (ILGO). The risk of a dilated conduit is the much-feared anastomotic leak. Therefore, prompt management of DGE is required. However, the pathophysiology of DGE is unclear. We proposed that post-ILGO patients with/without DGE have different gut hormone profiles (GHP). Consecutive patients undergoing an ILGO from 1 December 2017 to 31 November 2019 were recruited. Blood sampling was conducted on either day 4, 5, or 6 with baseline sample taken prior to a 193-kcal meal and after every 30 minutes for 2 hours. If patients received pyloric dilatation, a repeat profile was performed post-dilatation and were designated as had DGE. Analyses were conducted on the following groups: patient without dilatation (non-dilated) versus dilatation (dilated); and pre-dilatation versus post-dilatation. Gut hormone profiles analyzed were glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) using radioimmunoassay. Of 65 patients, 24 (36.9%) had dilatation and 41 (63.1%) did not. For the non-dilated and dilated groups, there were no differences in day 4, 5, or 6 GLP-1 (P = 0.499) (95% confidence interval for non-dilated [2822.64, 4416.40] and dilated [2519.91, 3162.32]). However, PYY levels were raised in the non-dilated group (P = 0.021) (95% confidence interval for non-dilated [1620.38, 3005.75] and dilated [821.53, 1606.18]). Additionally, after pyloric dilatation, paired analysis showed no differences in GLP-1, but PYY levels were different at all time points and had an exaggerated post-prandial response. We conclude that DGE is associated with an obtunded PYY response. However, the exact nature of the association is not yet established.

When initial diagnostic interventions for chest pain with ST-segment elevation do not yield expected results, an alternative diagnosis such as cholecystitis should be considered., Although chest pain with ST-segment elevation is often indicative of cardiac ischemia, it has also been described with surgical conditions such as acute cholecystitis. We report the case of a 34-year-old Caucasian female who was referred with symptoms consistent with acute cholecystitis. An electrocardiogram (ECG) showed unexpected changes with inferolateral ST-segment elevation indicative of an inferolateral myocardial infarct. Further investigations and analysis of the results along with the clinical picture meant an acute cardiac event was excluded. Gallstones were seen on ultrasound and an inflamed gallbladder, consistent with acute cholecystitis, was confirmed at laparoscopic cholecystectomy. This led to the resolution of her symptoms and a return to the isoelectric baseline of the ST segments on the ECG. Five previous cases of cholecystitis induced ECG changes have been described in the literature. This case describes the youngest patient with no previous cardiac disease. We review the literature and suggest the pathophysiological mechanism to explain these findings. When the initial diagnostic interventions for chest pain with ST-segment elevation do not yield the expected results, an alternative diagnosis such as cholecystitis should be considered.

Introduction Transomental herniation is a rare but recognised clinical condition, which usually presents as an emergency with bowel obstruction. It accounts for 1-4% of intra-abdominal herniations. We reviewed 3 patients found to have a transomental defect during elective diagnostic laparoscopy performed for chronic abdominal pain. To our knowledge, there is no case series reported in the literature on transomental defect in the non-emergency situation. Case presentation A retrospective case note analysis of 3 patients, found to have transomental defect during elective diagnostic laparoscopy, was undertaken. Data were gathered with respect to clinical presentation, investigations performed, transomental defect size and outcome of surgery. All patients were followed up for 6 months post-operatively. Three females (age range 18-35 years) were referred with a 3-10 year history of chronic intermittent abdominal pain, often postprandial. Blood tests, radiological investigations (ultrasound, magnetic resonance imaging/computed tomography, small bowel studies) and endoscopy were all normal. In each case, diagnostic laparoscopy revealed the presence of a peripheral defect in the greater omentum, but no actual small bowel herniation. No other pathology was found. These defects were resected, which subsequently led to complete resolution of the patients’ symptoms. Conclusion Chronic abdominal pain of unknown aetiology with normal radiological findings may be caused by intermittent obstruction due to small bowel herniation through a transomental defect. This should be considered during elective diagnostic laparoscopy, in the absence of any other obvious pathology. The omentum should be thoroughly inspected as a discrete entity and any such defects should be closed or resected.